Muscogee (Creek) Nation WIC Program
Completion of this form is required per USDA Federal Regulations to ensure that the patient under your care has a
medical condition or diagnosis that requires the use of medical formula or food that will mandate changes to their
supplemental food package. Please fax the completed form to the WIC office at 918-549-2989 or have your patient return
the document to the WIC clinic. Forms can be accessed http://www.muscogeenation-nsn.gov/Pages/WIC/wic.html
Medical Diagnosis/Qualifying Condition_______________________________________________________________
ICD-10 Code(s)_________________________________ Medical Documentation Valid for: □ 1 □ 2 □ 3
Months Name of Medical Formula/Medical
Prescribed Amount: □ Maximum Allowable per Federal Guidelines OR ____________________________ Per Day
Current Weight___________ Height___________ Date Taken (within 30 days of request)_____________________
After reviewing food packages on back, select foods allowed based on medical condition of this individual.
□ No supplemental foods, offering foods is contraindicated at this time. Provide only formula.
NFANTS (6-11 months)
□ Infant Cereal □ Infant Fruits □ Infant Vegetables □ Infant Meats
OMEN AND CHILDREN (12 – 60 months)
□ Milk □ Eggs □ Peanut Butter □ Cheese
□ Cereal □ Juice □ Beans □ Whole Grains
□ Fruits □ Vegetables
□ Issue Whole Milk: WIC provides low fat milk only for all participants ≥ 2 years of age unless contraindicated.
PECIAL INSTRUCTIONS OR RESTRICTIONS
ignature of Health Care Provider______________________________ Date________________________________
Provider’s Name (please print) ______________________________ MD DO PA ARNP CNS CNM
ame of Medical Office/Clinic ____________________________________________________________________
Phone Number (with area code) ______________________________ Fax#______________________________
For questions regarding this form contact our office at 918.549.2790 June 2015
This institution is an equal opportunity provider.
WIC USE ONLY
_____ Approved _____ Denied by:
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